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lGA yt�.iz�clRr �1+c• a SY+c,'tD AALICATION FOR PERMIT t R3— NorB o SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED F1. (Complete in Triplicate) Application Is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No.54g for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. - t NE 4� tluslr ►t4 c. -,3(O7kLot Size _ PM Job Address f -i �d� yr 1"�)f a., LC m!f•(J/Q7}9S Phone V Owners Name -I� Address //�� ,'' /� v m� 5 Ci/ rVjH^ Address License No. Phone S 6 contractor DG TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 1 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER % &GOTedL QorinpS DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES >Snz DISPOSAL FLD. PROP. LINE _ `_Viol f FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS — Lo I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing Y ❑ Industrial O Open Bottom ❑ Manteca Dia. of~ExcavationI Specifications ❑ Dornesiic/Private L)Gravel Pack ❑ Tracy Type of Casing_--� 11 , _I _ I1 Public ❑ Other I ❑ Delta Depth of Grout Seal Type of Grout J9QILYJAeg--. I I litigation —Approx. Depth I I Eastern Surface Sea] Installed taw " JJJ Repair Work Done ❑ Type of Pump l H.P. Stale Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth t Filler Material (Below 501 V TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION I I DESTRUCTION I 1 availab�e'wnys A tem to n In 200 permifeettted it public sewer is r� Installation will serve: Residence_ Commercial__ Other ` f c Sys Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg I Capacity No. Compartments PKG. TREATMENT PLT.❑ ) Method or Disposal Distance to nearest: Well Foundation Proerty Line I x LEACHING LINE ❑ No. A Length of lines tp th/size FILTER BED ❑ Distance to nearest: WeII FoundationopeM Line SEEPAGE PITS I I Depth I Size Number } SUMPS D Distance to nearest: Well Foundation Property Line li DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county oraihagces, state laws, and rules and regulations of the San Joaquin Local Health D3trict. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa tion laws of California." The applica u t call Por all requir in ctions. Complete drawing on reverse side. �N�� Signed X -. Title: /�f - Date: FOR EPARTMENT USE ONLY1.4 9A Application Accepted by Date /— d Area Pit or Grout Inspection by Date Final Inspection by Additional Comments: ❑ SO, 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 836-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009. Stk., CA 95201 FEE AMOUNT AMOUNT RE TIED CASN RECEIVED eV DATE RMIT'NO. 1 INFO ' �/} E�iaz4lR , ry .51 �: ` '70 2c v I� abTie) -r3e EM i�m